Incident investigation·August 28, 2025

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/28/25, stemming from incident report received on 8/1/25. LPA was greeted by Elizabeth Sandoval, Medication Aide, and the purpose of the visit was explained. Naylet Velazquez, Medication Aide/Second Designee, arrived shortly after to assist with the visit. Rosalie Sandoval, Executive Director, was contacted telephonically and was also informed about the reason for the visit. According to Unusual Incident Report (SIR) received on 8/1/2025, licensee self-reported that a resident was having sexual contact with another resident in the facility which was witnessed by a staff member who then reported the incident to the director. The incident happened on 7/24/25 in the evening. According to SIR, the incident took place at the facility between Resident 1 and Resident 2 (R1-R2). R1, indicated to staff, R2 is their friend but felt pressured by R2 to receive sexual advances which made R1 feel uncomfortable. LPA conducted interviews with Staff 1 – Staff 4 and obtained the following information: administrative staff have talked to R2 regarding the inappropriateness of their behavior toward R1. Staff are taking extra measures to supervise the interactions between R1 and R2. Staff are also conducting more frequent checks on R1 in their room and while spending time in the common areas of the facility to ensure R1's safety. Staff further indicated, R1 is safe and well taken care of by staff and no other incident has been witnessed or reported. Telephone interview with Ombudsman indicated that they came out to the facility to do a wellness check on R1 after the incident. Ombudsman indicated that the facility did everything they are supposed to do in this type of situation. Facility notified Ombudsman, licensing and R1’s conservator/responsible party about the incident. ***Continues on LIC 809-C Ombudsman further indicated that R1 did not express concern regarding the incident and appeared to be in good physical and emotional state when they interviewed R1 during their visit. Ombudsman further stated, “I don’t have any concern for R1’s safety. Director is in constant communication with conservator about R1, which I was able to confirm, via phone call with them.” Ombudsman also indicated that the conservator will continue to be in communication with the facility to get wellness updates on R1. No other incident has been reported to the Ombudsman. R1 was also interviewed during today’s visit and acknowledged the incident between R1 and R2. R1 stated, R2 is their friend, but they don’t want R2 to do this again. R1 indicated, no other incident has taken place and R2 is keeping their distance. R1 further indicated, they feel safe at the facility and feel they are being cared for by the staff. R1 stated they know they can report to staff if R1 feels they are in danger. LPA was unable to conduct interview with R2 due to R2 being away at the time of visit. LPA did not observe any immediate health and safety risks during visit. No further action is required at this time. No deficiencies were cited during this visit. Exit interview was conducted with Naylet Velazquez, Medication Aide/Second Designee. A copy of this report was provided.